Medical Aid terms and rules


Simple explanations for those complicated Medical Aid words!

Your very first step is to understand what the various medical aid terms mean.
This is critical to your understanding of what you are buying.

  1. Acute medicine - medicines required to treat a short duration, rapidly progressive illness, that is in need of urgent care.
  2. Acute conditions - are severe and sudden in onset - anything from a broken bone to an allergic reaction.
  3. Agreed tariff - The amount a scheme negotiates with providers they use, as payment for services done. Mostly applies to hospitals for ward and theatre, doctors, specialists and medicines.
    See How a Medical Scheme Pays Claims.
  4. Algorithm - a pre-defined way of treating or managing an illness or medical condition for the best results.
  5. Alternate healthcare providers - Providers such as dieticians, hypno-therapists, acupuncturists and nutritionists providing complimentary care.
  6. Benefit - treatments, procedures and medicines covered by the medical aid you join.
  7. Chronic conditions are long-developing conditions (usually lasting more than 3 months), which need ongoing treatment. Conditions such as diabetes or hypothyroidism. They may require life-long treatment with daily medicine.
  8. Chronic disease list (CDL) - A list of 27 prescribed minimum benefits (PMBs) chronic conditions that are covered by all medical aids.
  9. Co-payment - a portion of the cost of treatment that a medical aid levies on the member.
  10. Principal member - the main member of the scheme. The principal member pays a larger contribution than the dependants do.
  11. Dependant member/s can be:
    (Medical schemes refer to principal members and dependants as beneficiaries.)

    - Your spouse or life partner;
    - Your dependant children;
    - Other members of your immediate family for whom you are liable for care and support;
    - Any other person who is allowed as a dependant under the rules of a medical scheme.

  12. Day-to-day benefits - cover for treatments performed outside of admission to hospital. (Can include casualty if you are not admitted after treatment.) Costs like doctor, specialist consultations, medicine, dental, optical, physio etc.
  13. Generic medication - non-branded medicine with the same active ingredients, similar strength and performance to branded medication but at a lower cost.
  14. Waiting periods - The Medical Schemes Act allows medical schemes to impose waiting periods on new members.
    See How a Medical Scheme Pays Claims.
  15. Late-joiner penalties - schemes can impose late-joiner penalties on individuals who join after the age of 35; - those who have never been medical aid members; - or those who have not belonged to a medical scheme for a specified period of time since April 2001.
    See How a Medical Scheme Pays Claims.
  16. Designated Service Provider (DSP) - these are healthcare providers like doctors, chemists, hospitals etc. that are contracted to your scheme, as the first choice when you need diagnosis or treatment. They are generally paid a specific rate for these services and bills are fully covered.
    If you choose not to use a DSP, you could be liable for a co-payment. If there is no DSP close to you, you should be able to use any provider.
  17. Disease management programme - a pre-defined programme to manage a chronic condition. You may have to join a programme to access benefits.
  18. Exclusions - even though medical aids cannot refuse a membership, they can exclude certain medical conditions and procedures, like cosmetic surgery and self-inflicted injuries.
  19. ICD-10 codes - A global disease classification and coding system to identify and diagnose symptoms and procedures. The medical aid bases benefits for a plan on these codes and they must appear in any claim submission.
  20. Prescribed Minimum Benefits (PMBs) - Medical schemes must cover a set of defined benefits allowing all members access to certain minimum health services, regardless of the plan they join. Schemes must pay in full for the medical care, pathology, radiology and medication costs related to the diagnosis, treatment and care of 270 medical conditions, which include 27 common chronic conditions.

    You still need to tell the medical aid about your condition, to ensure that your treatment is paid for correctly. They can request you use a specific provider (DSP).

  21. Hospital plans cover a range of treatments and procedures when you are admitted into a hospital. They include chronic medicines and some will include day-clinic and procedures done in a doctor's room. There is a plan that pays dental costs, even though it is a hospital only plan! You pay for all day-to-day costs.
    The best hospital only plan (that pays dentistry as well)!
  22. Comprehensive plans cover in-hospital benefits with a medical savings fund for day-to-day costs. You can spend the funds as you wish, within certain limits.
    Once savings are spent you pay further costs that year, except with plans that have an above-threshold benefit.

    These plans provide ultimate peace of mind, ensuring all your medical expenses are covered by your provider and are recommended if you have or anticipate significant medical expenses, or just want to know that you and your family are fully covered in the event of ill health.

    A low premium, comprehensive plan that pays dentistry - so you do not have to use your day-to-day savings!

  23. Traditional plans offer pre-defined benefits and limits, from expensive, comprehensive plans to limited, more affordable plans. Benefits are in rand or a fixed number of consultations and treatments.
  24. Network plans - you choose to use providers linked to the scheme and get discounted premiums. Networks of hospitals, doctors, pharmacies, optometrists and dentists.

    This does not mean you receive sub-standard treatments. A good network medical scheme should ensure that it contracts with practitioners who provide quality care and that its member's claims will be paid in full. Most premiums are related to your income, so those with lower incomes can still belong to a medical plan. Ideal, affordable plan for pensioners and families on a strict budget!

    There is a good, low-cost network plan, with an option to use any hospital you wish!

  25. National Health Reference Price List (NHRPL) - a set of baseline tariffs designed by the Council of Medical Schemes (CMS). It serves as a rates guideline for healthcare practitioners and medical aid schemes.
  26. Pre-authorisation - all hospital admissions need to be authorised by your medical aid prior to your being admitted. An emergency admission can be authorised within 24 to 48 hours. Please check your scheme rules.
    If you fail to do this, your scheme will not pay claims!
  27. Risk - any benefit that is not covered through the member’s day-to-day fund.
  28. Self payment gap - some plans offer a safety net, where, once the money in a day-to-day savings fund is used up and the claims submitted have not reached the pre-determined threshold level, the member self-funds further claims (and submits then to the scheme) until the threshold level is attained. Above threshold benefit - once claims have accumulated to the pre-determined threshold level, the plan then pays further out of hospital costs in terms of the rules.
  29. Scheme rates - the Department of Health publishes rules and tariffs for certain healthcare services and procedures that are performed. This is known as the NHRPL or National Health Reference Price List.
    However, these are only guidelines and private providers are free to charge what they like.
    Most schemes then take these NHRPL rates, add around 2 – 5% to them and this is know as that scheme's rate of claims payment.
  30. Sub-limit - A defined limit that applies, in addition to the overall limit, for a particular benefit.

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Last update: March 28, 2024